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A couple of years ago, I spoke privately with a highly admired administrator in a large humanitarian aid organization. Let's call him Pete. Over dinner, I asked how he felt about his long, successful career. Rather than mention his triumphs, he began to cry quietly while he shared an experience nearly thirty-five years in the past. As a relief worker in Africa, while touring a region ravaged by genocide, he had to decide which villages would get food and which would likely starve. There simply was not enough for everyone. The face of one particular child he encountered, who would not be receiving food in time to save her life, was imprinted on his soul. He still has nightmares about that moment. Despite all he accomplished since, he feels tortured by the decisions he made that day – some got fed, others did not. My friend will carry this wound forever.
At the Institute, we regularly speak with aid workers and emergency responders who experience personal traumatic events like serious accidents, assaults, or injuries. Others are vicariously traumatized by what they see or hear while doing their work. In both cases, brain function and/or structure can be altered in a way that produces significant emotional distress such as anxiety, depression, anger, and suspicion. But, neither phenomenon adequately explains what happened to Pete.
Recently, there has been growing recognition of a related but different kind of emotional pain referred to as moral injury. Clinicians and researchers are finding evidence of what can best be described as “wounds to the soul.” They result from violations of deeply held beliefs about what is right. Decisions like the ones Pete disclosed, when one must choose among “bad” options, may force people to act contrary to their beliefs. Frankly, I’ve yet to meet anyone not troubled by the need to pick the “lesser of two evils.” When the stakes are high, such choices can haunt you forever.
Over the years, I’ve found that moral injury can result from a variety of additional causes: inability to stop others from committing atrocities; carrying out management directives that violate personal values; witnessing random suffering caused by natural disasters; tolerating overwhelming injustice. These experiences leave lasting scars of guilt on the psyche/souls of those who feel responsible but unable to stop “evil” from occurring. In addition, most of us live with the shame of knowing we made wrong choices that hurt others – errors of judgment or mistakes due to moral weakness. Here, too, there may be lasting moral injury.
The experience of moral injury may cause feelings of personal regret, guilt, shame, or failure. There may also be growing anxiety, depression, anger, or suspicion similar to that experienced by other trauma victims. A loss of faith in God, suspicion of others’ motives, lack of self-confidence, and a growing fearfulness or hopelessness may accompany these emotions. While not yet recognized as a clinically diagnosable condition, moral injury appears to me to be a very real experience.
Recent research on veterans returning from Iraq and Afghanistan provides convincing evidence of the significant and lasting impact of moral injury on the lives of those forced to commit or witness actions of violence inherent in warfare. Few veterans are unaffected by these experiences. Most are left with deeply seated conflicts regarding what was right and wrong, good and evil, necessary and unnecessary.
Military veterans are not the only ones left morally injured after a deployment. Ironically, individuals who rescue victims of humanitarian disasters and local emergencies often face the same “no win” situations. Like Pete, they may need to make decisions that hurt or kill others. They may be unable to accomplish sufficient “good” in particularly “bad” situations to leave them at peace. They may witness things that no human being should ever see. Whether or not they are at fault, the resultant moral injury can leave lasting wounds that few understand or disclose to others.
While I recognize the need to tread carefully when using terms like “good and evil” and “right and wrong,” there seems to be a sense of human morality that transcends religious, socioeconomic, and political worldviews. Added to this are personal beliefs and experiences that shape who we are and what we stand for. When this tapestry of meaning and purpose is violated, lasting moral pain and injury may result.
Although the concept of moral injury is relatively new in the research literature, we’ve witnessed its impact throughout our 15 years of fieldwork with responders worldwide. Because this is one of those “messy” topics that can lead to misunderstanding and worse, we’ve been hesitant to say much about it publically. However, we’ve decided to be more outspoken on the topic in hopes of stimulating further dialogue, research, and collaboration. If aid workers and emergency responders are indeed experiencing moral injury, this deserves our attention.
In my next post, I’ll describe what we’re learning about how to recover from moral injury, based on research and field experience.
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